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Ok so I had a scare tonight when administering a new narctotic order. HX. Resiedent has broken femur and pre existing MS. Sent to Er where we are told in the ltc facilty that they will no be treating the fracture. Pain is 10/10 at all times since readmission. Nurse practioner calls doctor on my behalf to increase medications. Currently the resident in on 20 mg oxycontin BID with dilaudid 1mg 1 to 2 tabs q 4 hr for breakthrough pain. The NP nad doc decide that they should streamline the meds and switch the oxycontin to hydromorph contin 9mg with the dilaudid (being the same med class). I come in on Evening, resident received the first dose of 9mg in the monrnign and I ask what her pain scale is ( at 10/10) so I give the extended release as ordered and give prn .
Residnet is very snowed and scaring me. O2 sat 90% and resp 12. Doctor comes in and suggests we reduce the meds tomorrow and monitor. Rn charge nurse comes up and assessed the resident as not needing narcan though she is mostly unreponsive. I monitor the remainder of my shift with no change.
I left feeling a bit uncomfortable with the situation....but I followed orders and wanted to only help her. What would you have done
The fracture can be repaired under spinal anesthesia (the majority are). I agree with the others. That is the only way the pain will be alleviated. Depending upon the type of fracture, the procedure can be done in 15-20 min, if a compression screw is used. I also agree that the orthopod is blowing her off. So sad.
There is not enough information to know why they aren't repairing the fracture.
Narcan is going to be shorter acting than the po narcotics and it is going to likely have to be redosed 1-2 times because the patient will renarcotize.
Narcan isn't needed in this case, if you are worried about the patient get an order for O2 via NC prn but otherwise let her sleep.
Toradol would be a bad idea in an unstable fracture since bleeding can still be a major problem.
It's a risk for bleeding no matter what :) Since surgery isn't on the boards for this one, it could be effective We never used it for more than 5 days post-op.... but with "no-op" seems worth a shot????? There's always protonix
GI bleeding seems to be the source most looked for. JMO
http://www.druglib.com/druginfo/toradol/indications_dosage/
Does the pt have any sort of renal dx? That would be my worry FIRST when considering Toradol.
And yes, Toradol does increase bleeding. We don't use it for surgeries like prostatectomies, for example.
A hip compression screw would be a possibility. A Gamma Nail might be too much for this lol, but we have done it before on 97+ year old ladies and they did just fine. Absolutely under a spinal.
Does the pt have any sort of renal dx? That would be my worry FIRST when considering Toradol.And yes, Toradol does increase bleeding. We don't use it for surgeries like prostatectomies, for example.
A hip compression screw would be a possibility. A Gamma Nail might be too much for this lol, but we have done it before on 97+ year old ladies and they did just fine. Absolutely under a spinal.
That's good to know that surgery may still be an option...the last pt I had with a fx...he had such bad osteoporosis that the surgeons said surgery was not an option, the hardware just wouldn't heal. However he did have some special brace placed, I can't remember the name of it. I'm a cardiac, tele kind of girl...ortho always makes me cringe and run to my sister units begging for help.
I agree with many of the previous posts - an anti-inflammatory would help, but as you've said, she has MS, are they giving her any anti spasmotics? With all the narcs, Valium would be out - but it works great as an antispasmotic - how about Zaniflex? The entire area around the fx is most likely inflamed, and this may help.
I too would not worry about her sat and RR - a little "unofficial" O2 via NC or even blow by may help ease your discomfort.
She isn't the first I've seen that they have decided not to repair, but she is the first that I've heard of where pain is always a 10/10. Obviously, they have to get that controlled. A combination of Narc's, anti-inflammatory, and anti-spasmotic's is what I would suggest.
Just my
I'm curious on how a non ambulatory patient got a femur fracture in the first place. What was the mechanism that caused a non ambulatory patient to get a femur fracture. The femur is pretty hard to break in the absence of any bone pathology.
I would be cautious of femur fracture and the use of Toradol, as there can be a lot of bleeding into the thigh from the fracture itself (can be over up to 2 liters according to ATLS), from injury to the muscle, and bone itself. There can also be vascular involvement from driect damage from the bone. There are some femur fractures that the repair may involve more risk than leaving it to heal depending on the situation.
Information on the fracture itself is vague so there is not enough information to determine IF the fracture should be surgically stabilized. Is it a femoral neck? Is it a spiral shaft injury? Is it a comminuted mid shaft fracture? I can agree with the O2 support and letting her finally had some peace. I also agree with the idea of antispasmotics for not only do MS patient suffer with a ton of spasms from their diease (and they are very painful) the fracture itself causes severe spasms in the injured thigh.
It's a risk for bleeding no matter what :) Since surgery isn't on the boards for this one, it could be effectiveWe never used it for more than 5 days post-op.... but with "no-op" seems worth a shot????? There's always protonix
GI bleeding seems to be the source most looked for. JMO
http://www.druglib.com/druginfo/toradol/indications_dosage/
(just for grins)
You have unstable femur fracture that could get worse at any time. You would be worried about the fracture causing more damage and bleeding not a GI bleed in this instance. Not to mention that Toradol might cause more problems in healing/fusing of the bone. http://www.medicine.ox.ac.uk/bandolier/booth/painpag/wisdom/NSAIbone.html
This has been so tough for me. Im a new grad in LTC and I feel this resident is acute. She used to be a 2 person transfer and was recently changed to a mechanical lift. She is in her sixties and was not happy with the transfer change because it was much easier to get help without waiting for a lift. The family had her status changed back to 2 person. A week later she was transfering from the toilet when she was unsupported for a few sconds when her shoes sliiped onthe floor. Resident stated her leg twisted. Now we have a distal femoral # at the epiphysis. I think I may ask to hace a family conference with DONC. I thought she was doing so much better on the oxycontin and dont know why they switched to hydromroph contin. Now she wont eat or drink much....wish me luck tonigh and thanks for the support and ideas.
wooh, BSN, RN
1 Article; 4,383 Posts
With the MS, I was guessing it was the non-ambulatory rather than 100 years old and too risky for surgery. I have a family member that's non-ambulatory. Didn't mean her femur fracture didn't require surgery (and had to fight to get it for her too, ergh!) As said above, that's the only real fix for the pain. And if she's 10/10, she needs the fix, poor thing. (Like said above, not aimed at OP, aimed at whoever thought she didn't need the surgery. I'm sure I'm preaching to the choir with that one.)
Whatever you do, avoid the narcan. I remember a cancer patient that was full code except for narcan. He wanted everything done, EXCEPT narcan. He'd gotten that once (after a tech had been pushing his PCA button while he was sleeping) and NEVER wanted it again. Full code, but if it was narcan or die? He'd take death.
If I had a femur fracture, you'd have to give me some sort of cocktail that included a clonidine patch, a fentanyl patch, some darvocet stolen from an old person's cabinet since it's no longer available, a dilaudid PCA and probably an epidural PCA to go along with it, and of course the muscle relaxants. And I almost forgot, traction to keep it stretched out. Of course, then I'd go crazy being stuck in the bed all day, so you'd have to add some anti-psychotics to the list.
I'm a wuss. I ever fracture something, EMS should just wheel me straight on into surgery.